Healthcare Provider Details

I. General information

NPI: 1205023173
Provider Name (Legal Business Name): TINA MARIE BUTT NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9485 MENTOR AVENUE SUITE 210
MENTOR OH
44060-8723
US

IV. Provider business mailing address

7590 AUBURN ROAD., SUITE 014 ATTN: MEDICAL STAFF
CONCORD TWP OH
44077-9176
US

V. Phone/Fax

Practice location:
  • Phone: 440-255-5571
  • Fax: 440-205-5744
Mailing address:
  • Phone: 440-354-1899
  • Fax: 440-354-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberCOA.09534-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.09534
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: